Preparing for Emergencies Guidance

Section 5 - Essential Elements of Emergency Response

This section highlights the essential elements that are required to be in place so that Health Boards can respond effectively to major incidents. There are 3 key elements of emergency response: Preparing, Responding, and Recovering. All CCA responders must aid in this process, depending on their roles and functions (e.g. Health Boards will lead response and recovery; IJB functions lend themselves most effectively to strategic planning of health and care services for emergencies, as well as normal business).

Command, Control and Coordination (C3)

5.1 In general, emergencies are local, time-limited, and effectively dealt with, either by emergency services or the designated hospital’s Emergency Department. However, some will be of a greater magnitude with potential consequences beyond the Health Board area which necessitate a higher level of regional or national Command, Control and Coordination.

5.2 In times of pressure and when responding to emergency incidents, internally or externally, Health Boards need a structure which provides clear leadership, accountable decision- making, and arrangements for communicating up-to-date information. C3 (Command, Control, and Co-ordination) is a widely recognised structured approach to incident management under pressure.

5.3 C3 structures have historically been described as Gold (Strategic), Silver (Tactical/Operational oversight) and Bronze (Operational Delivery) commands. Joint Emergency Service Interoperability Programme (JESIP) principles expand on and clarify key elements and should inform the planned structure of any response.

Co-locate: Is the principle of responders using the same location, physical or virtual, to plan a mutual response. In a post-covid world and given the complexity of some incidents requiring multi-agency responses, virtual settings can be used to bring together wide ranges of partners at short notice. This enables an approach which satisfies the CCA-mandated duty to co-operate between agencies with very different remits.

Communicate: Communications should be clear, concise, and accessible, avoiding technical jargon and abbreviations.

Co-ordinate: Co-location and clear communications enable co-ordinated responses between CCA responders, whether on scene, or at a tactical or strategic command group. This minimises the risk of duplicated effort or conflicts of interest.

Jointly understanding risk: In responding in a co-ordinated fashion, jointly understanding risk and shared situational awareness both contribute to and benefit from the joint working enabled by the other JESIP principles above. All organisations identified as Category 1 responders under the CCA should use these principles to fulfil their duties to co-operate in response to major incidents.

The application of simple principles for joint working are particularly important in the early stages of an incident, when clear, robust decisions and actions need to be taken with minimum delay, often in a rapidly changing environment.

Co-locate

Co-locate with other responders as soon as practicably possible at a single, safe and easily identified location.

Communicate

Communicate using language which is clear, and free from technical jargon and abbreviations.

Co-ordinate

Co-ordinate by agreeing the lead organisation. Identify priorities, resources, capabilities and limitations for an effective response, including the timing of further meetings.

Jointly understand the risk

Jointly understand risk by sharing information about the likelihood and potential impact of threats and hazards, to agree appropriate control measures.

Shared Situational Awareness

Establish shared situational awareness by using M/ETHANE and the Joint Decision Model.

Responsibilities

5.4 Category 1 and 2 responders must have pre-determined C3 arrangements in place at all levels to respond effectively and efficiently to a major incident that it can either manage alone, or through support provided as part of a wider multi-agency or national response. Effective C3 arrangements will:

• bring the right people together at the right time, using links with multi- agency response structures
• be adaptive, able to respond to different types of emergencies
• include functional arrangements for making decisions, collecting, and sharing information quickly, accounting for physical and virtual ways of working
• be able to be activated quickly with the necessary personnel, standard operating procedures, and equipment
• have clearly defined roles and decision-making responsibilities for Executive-level Directors, with other staff delegated to assume control of an internal incident or an external one as part of multi-agency strategic command group
• have clearly defined processes for maintaining appropriate, contemporaneous records and documenting the incident

5.5 An adequate pool of staff should be trained as loggists to support the management of an incident or response. It is essential that incident logs produced reflect best practice standards and that loggists understand the evidential value and rationale of a robust audit trail.

5.6 All staff identified to assume C3 responsibilities should be given an appropriate level of training in line with the competences for the various roles they are expected to fulfil.

Mutual aid agreements

5.7 Mutual Aid Agreements are an important aspect of emergency preparedness. Health Boards can use these to ensure access to appropriate supplementary and/or specialist resources and support from other health organisations, as stated in NHS (Scotland) Act 1978 s 12J. Health Boards have discretion to tailor the specifics of any mutual aid agreement with any other health provider to promote the best emergency response.

Responsibilities

5.8 The Chief Executive must ensure the organisation has a mutual aid agreement with other Health Boards, responding partners and other relevant organisations not covered by the CCA in the RRP area and beyond if necessary. The agreement should clearly outline what aid might be required, what can be offered, who the partners are, and associated governance arrangements. It should be reviewed and revised annually. See sample Mutual Aid Agreement in Appendix 3.

5.9 Mutual aid requests for support should be formally triggered by the Chief Executive or named Deputy to maintain normal service provision. This should take place at an agreed point between recipients and providers of mutual aid. This will usually be after the Health Board has invoked its surge capacity plans and the incident C3 Group concludes that the capacity and capability thresholds for operating safely have been reached. Chief Executives or their named Deputy do however have autonomy to agree different thresholds for mutual aid triggers.

5.10 If the incident is likely to be of a longer duration or deemed to require coordination or mutual aid on a larger scale, Scottish Government Resilience Room (SGoRR) may be activated to fulfil a national, strategic coordination function and to ensure that government assistance is provided if required. (See Roles and Responsibilities, Section 6). Major Incidents with Mass Casualties have additional response structures which can be found in Section 7 of this guidance.

5.11 Mutual aid arrangements should be properly accounted for. Any agreed distribution of demand due to a major incident response should documented to allow for a review of activity to clearly understand what should be documented, why, and how, as part of routine post-incident reporting. This may include, for example, accounting for the number of patients moved via business-as-usual processes in response to a major incident.

The Major Incident Plan

5.12 Major Incident Plans are the culmination of risk assessments. They reflect that the organisation understands the impacts that could arise from various types of major incidents or emergencies and is prepared for them. The plan provides the basis for assuring an effective and efficient response.

5.13 Health Boards should have an overview of all emergencies that have occurred in its accountable area, as well as lessons identified from the response to and recovery from those emergencies. These lessons should be shared with other Health Boards, responder organisations and the SGHSCD to enhance collective learning. Precise formats for lessons identified should be flexible to account for the diverse nature of emergencies but always with accessibility in mind.

Planning Responsibilities

5.14 The Major Incident Plan is a key component of preparedness. Health Boards should have, and routinely review these, whether to comply with their CCA responsibilities or as best practice and/or for assurance if they have no CCA-defined duties. The plan should set out how to prepare for, respond to, and recover from various types of major incidents and should:

• have appropriate governance arrangements and set out responsibilities for carrying out the plan
• be consistent with multi-agency working, especially with partners represented within the same Resilience Partnership, and link to any multi-agency response that the Health Board has a role in, such as public communications and the Scientific and Technical Advisory Cell (STAC Guidance). (See information on communications at the end of this section)
• reflect the requirements of applicable legislation and guidance such as the Civil Contingencies Act 2004
• have the capability to deal with all the specific incident scenarios and issues identified in this guidance, specifically Section 7, such as CBRN, mass casualties, communicable diseases, burns injuries and meeting the needs of children, young people, and vulnerable people
• identify where and how specialist advice may be obtained or accessed, especially out-of-hours
• describe local command, control, and coordination (C3) arrangements, identify lead officer posts (at strategic, tactical, and operational levels), and out line their roles and responsibilities
• identify mutual aid arrangements with neighbouring Health Boards and other key agencies and how when they should be triggered
• identify reporting procedures and links with RRPs, Scottish Government Health and Social Care Directorates (SGHSCD) as necessary, and how and when they are to be triggered
• identify resources to be allocated or accessed to deal with various types of incidents in line with defined planning assumptions, as identified during the Health Board’s assessment of risks (e.g. impacts, mitigations, contingencies)
• identify the staff requirements and mobilisation arrangements to respond to various incidents and how the impact on normal services will be addressed
• be regularly reviewed (in the light of exercising, training, lessons learned from incident debriefs and policy changes), and endorsed by the Civil Contingencies/Resilience Committee and/or the Health Board
• include an escalation framework for responding to major incidents of varying intensity

5.15 Major Incident Plans should be:

• exercised in full at least every 3 years
• tested through a tabletop exercise – every year
• communicated/cascaded within the organisation and to partners – every 6 months

5.16 For Category 1 and 2 responders under the CCA, these actions should fulfil the legal duty to maintain effective emergency responses, while remaining advisable for other Health Boards.

Reporting Major Incidents

5.17 Health Boards should ensure that all relevant staff are aware of the Scottish Government: Health EPRR reporting arrangements using the agreed Situation Report (SitRep) pro- forma. These arrangements must be used when all the following apply to a major incident:

• occurs within a Health Board area
• has been declared by an RP partner that requires the deployment of healthcare resources
• creates significant service pressures for the Health Board and is likely to impact on business as usual

5.18 The reporting frequency will be agreed by the Health Board representative and SGHSCD depending on the nature of the incident and the assessment of its impact on the Health Board(s).

Responsibilities before and during a response

5.19 The Chief Executive must ensure that arrangements and resources, including financial commitments, are in place to enable adequate training, exercising, and testing of the Health Board’s emergency preparedness. Accordingly, a budget should be allocated to meet the costs of the agreed programmes. Health Board senior leaders should be advised at least annually of the Board’s state of preparedness.

5.20 To meet their emergency planning responsibilities, Health Boards should have:

• an annual training and exercising plan, the implementation of which is monitored and recorded
• a process and system for recording and reporting the outcome of exercises and for ensuring that lessons-identified are learned and are incorporated into revisions of plans and protocols
• training/skills records to help inform capability analysis that are kept up to date

5.21 Public bodies from across the health and care services, including acute services, public health, primary and community care, IJBs and HSCPs, should be involved in planning exercises. How these exercises are co-ordinated can be adapted to the best fit for local circumstances; for example, it may be co-ordinated by a Health Board, IJB, or Regional/Local Resilience Partnership. This should also include any contractors providing these services on behalf of a public body, which becomes a legal duty were identified as a responder under the CCA. Health Boards should identify risks specific to their contexts and duties and prepare specific scenarios for exercise in response to these tailored risks.

5.22 Wherever possible and beneficial, Health Boards should collaborate with each other to organise and participate in joint exercises, involving multi- agency partners where practical. The lessons identified from these exercises should be disseminated across the service via appropriate networks (e.g. LRPs/RRPs) as a means of enhancing the collective learning and overall resilience of Health Boards in Scotland.

5.23 Training, testing, and exercising should take place in the context of a training needs analysis and a progressive, targeted, and graduated training programme that reflects the roles and responsibilities of staff in particular operational settings. Senior managers should ensure that appropriate staff are released to participate in relevant training programmes.

Communication

5.24 Communication with the public is a duty under the CCA and plays a central role in preparing for, responding to, and recovering from emergencies. Effective communication requires Health Boards to think strategically about how they communicate internally, with one another, and how they communicate with patients and with members of the public.

5.25 During an emergency, Health Boards must cooperate with other agencies to develop a communications strategy and issue information that is clear, timely, relevant, and accurate. Each of the 3 regional resilience partnership areas has a public communications group which Health Boards are expected to participate in. The public expect to be informed quickly and efficiently and, in an incident that has potential health consequences, they will look to the NHS to communicate with them both directly using websites and social media, as well as the mainstream news media.

5.26 Consulting with the media during an emergency is a resource-intensive operation. It requires those involved to have the necessary skills and training to cope with a surge of repeated requests for information, especially in the early stages of a major incident. Media reporting will affect how the emergency and the response to it are reported and that, in turn, can enhance the effectiveness of that response, both immediately and in the longer term. Effective engagement with media organisations should therefore form part of planning.

Communications Responsibilities and Preparations

5.27 Effective and resilient telecommunications systems are essential in enabling C3 groups to communicate with key personnel internally and externally during a major incident. Therefore, Health Boards should ensure that:

• appropriate telecommunications systems, which are fit for a range of emergency scenarios, requiring swift and reliable access by the staff who need them at short notice, and accompanying protocols for their effective use in emergency situations, are in place
• all staff who may be called on to fulfil a C3 function are suitably trained, experienced, and empowered to use the telecommunications systems in emergency situations
• communications testing exercises take place, with precise frequency to be determined by risk assessment and mitigation practices undertaken by the Health Board
• they work with the Scottish Government, have effective bilateral channels for communicating information to and receiving information from the Scottish Government and relevant responding agencies, whether through standardised on-call numbers, designated in boxes etc.
• they work towards a communications system which is resilient in the event of a major utilities power

5.28 Health Boards should appoint a Lead Communications Officer who should participate in the multi-agency strategic communications group formed to deal with the incident. The following guidance is presented under the various IEM activities (see Section 4 for further information on IEM).

5.29 Health Boards must have a communication plan (see Appendix 4), which is developed in conjunction with the Resilience Partnership and integral to its Major Incident Plan. They should ensure that managers responsible for emergency response are familiar with media needs, methods, and time schedules, and should prepare and train them and other appropriate staff for media liaison duties.

5.30 The communications plan should:

• outline the roles and responsibilities of the organisation and staff (particularly in the communications department) at various levels, the resources to be made available to them and the use of websites and social media
• indicate the procedures to be followed by the on-call Communications Officer in the event of a media enquiry or a statement by a member of the public on social media alerting the Health Board to a possible incident
• indicate how and when NHS 24 emergency helplines and its social media outlets will be used to keep the public informed
• indicate actions to be taken at various phases during and after an emergency has occurred
• be exercised, and the communications arrangements should be tested in as practical a way as possible. All training and exercising should take account of lessons identified from previous emergencies and exercises

5.31 The communication plan as a whole and the specific arrangements for communicating with the public and staff should be assessed against Equalities and Human Rights legislation (see Section 3).

5.32 Use of social media can reach a vast and varied audience in a short period of time, respond to requests for information, answer queries or counter rumours and inaccurate information. Using social media in a coordinated way with multi-agency partners can have a positive effect on public perception and reassurance.

5.33 Health Boards with responsibilities for major incident response and whose risk assessment indicates they will need to engage with the public should:

• have access to a suitably equipped and accessible space for use as a Media Centre in the event of an emergency
• have their own website and identified staff with access to update the website 24 hours a day. Consideration should be given to:
• communications departments having the ability to make their websites a low graphic text- only version in the event of an emergency
• having a mobile-friendly version of the website so that potentially large numbers of people can visit the site using mobile devices
• have in place social media platforms
• ensure that communications team staff have 24-hour access to the social media outlets and be trained in how to use them to disseminate “real time” information to the public

Response

5.34 In relation to the response phase, a communications plan should clearly set out:

• the procedure to be followed in the event of a major incident being caused or suspected to be caused by an act of terrorism
• the potential consequences of security being imposed on casualties and the hospitals treating them
• a communications procedure protocol is agreed with multi-agency partners, as far as this is possible, in advance. This will help ensure that:
  • essential healthcare personnel are not prohibited from entering hospital grounds or reporting for duty
  • media briefings on site that are coordinated by Police Scotland and cleared by the Health Board’s Senior Communications Officer
  • clear and timely messaging is communicated to staff who normally work at the hospitals
• the procedures and standards to be followed at first and subsequent media briefings
• the point at which assistance will be required from communications staff from other Health Boards in the event of a major incident/ emergency and consult with the Scottish Government Directorate for Communications

5.35 Patient confidentiality and staff’s right to privacy must be maintained during an emergency. No identifiable information about patients being treated should be released without first checking with Police Scotland and the consultant who is organising their care. Interview or photographs must not be permitted without the consent of the patient concerned.

5.36 Staff who respond to an incident may experience emotional distress and/or work-related stress from working beyond business-as-usual pressures. Health Boards should ensure they have appropriate resources in place to support the wellbeing and mental health of their staff.

Internal Communications

5.37 Internal communications are also important during emergency situations. Any major incident will have an impact on the local community in which staff live and they will have an obvious need to be informed. While staff will get updates from the external communications channels outlined above it is good practice to disseminate regular updates, including key messages and reassurance, to staff through agreed internal communications channels in line with internal communications protocols.

High Profile Person visits

5.38 High profile persons will often wish to visit the site of a major incident and/or hospitals involved in the response to it. They may also be admitted to NHS facilities as patients. Health Boards should have a Business- as-Usual protocol for such occasions that has been agreed with key partners.

Recovery

5.39 It is likely that a major incident could last several days, weeks or even months. While local authorities may lead the recovery phase, it may be necessary for health information to be provided by Health Boards in an ongoing, consistent manner during this period as part of a process of public reassurance. This may have resource implications for the organisation. NHS 24 has a key role in assisting the Health Board on such occasions by acting as a point of contact for disseminating information and/or providing helpline support.

5.40 When planning for emergencies, incidents are split into two distinct phases: response and recovery;

• response is characterised by immediate lifesaving activities using rapidly deployed resources (including the Mass Casualty response)
• recovery concentrates on supporting organisations, individuals, and their communities to make sense of their experiences, heal from injuries and recover from illnesses (including Care for People)

5.41 Health Boards have a role in both and some of their responsibilities during Recovery can include:

• maintaining the Scientific and Technical Advice Cell (STAC) to support decision making
• exploring and responding to the Community Health Impacts of the incident through Community Impact Assessments and the subsequent Joint Strategic Needs Assessments
• developing specialist care pathways to support people whose health (emotional and physical) has been affected
• establishing data collection processes to inform primary and secondary service development and resourcing
• supporting the multi-agency recovery effort with health and care organisations, community organisations and other key partners

5.42 To enable this, it is important to include consideration of the recovery phase when developing reasonable worst-case scenarios and planning assumptions as it is often during this second phase of an incident that the most resources are needed.

5.43 The term ‘recovery’ is often seen differently depending on the individual/agency/community’s role in an incident and for affected individuals and communities, the term ‘recovery’ is often problematic, particularly in incidents when people are still living with the consequences of the emergency.

5.44 Many of the outward facing activities started by the Health Boards during the response phase will need to continue into recovery. For example, maintaining help lines, providing community information, and supporting colleagues involved in responding to the emergency.